Large Pituitary Adenoma: Resection Principles

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This video further describes the techniques for resection of large or giant pituitary adenomas. A 52 year old male presented with visual dysfunction and chiasmal syndrome. MRI evaluation reveals this large pituitary adenoma, significant extension into this sphenoid sinus is apparent. It has sort of a snowman shape and morphology, and it can be difficult at times to remove this part of the tumor because of the narrow neck at the level of the sellae. It is also important that all the hormonal abnormalities are cruelly diagnosed prior to the surgery. In this case, this patient did not have any significant hormonal dysfunction. A transsphenoidal operation was undertaken, here you can see the sellae. Only removal was extended from one, cavernous sinus to the other all the way from the tuberculum sellae to the area of the clivus. The dura was opened by a cruciate incision. The gelatinous tumor was removed using ring curettes it's best to focus the desection first posteriorly then laterally and much later superiorly and anteriorly in order to avoid immature, or early descent off their diaphragms sellae. Here you can see using the suction device within the resection cavity to maximize the efficiency of the tumor removal. Getting the tumor over the diaphragms sellae is left alone, even though it's easily visualizable, and tempting to remove it. Angle endoscopes, especially the 30 degree endoscope is quite effective to remove the tumor over the medial wall of the cavernous sinuses. The MRI can exaggerate the extent of invasion within the cavernous sinus, and therefore the surgeon should follow the intraoperative findings in terms of removal of the tumor. There is often a very intact medial wall of the cavernous sinus separating the tumor from the intracavernous contents Here again, focusing on tumor removal along the medial walls of the cavernous sinus. And working within the resection cavity, endoscopic visualization is significantly more than microscopic visualization in terms of alllowing the surgeon to be more aggressive with tumor removal, especially around the corners. One can visualize better using the angle endoscopes, and be more aggressive. You can appreciate why adequate tumor removal is only possible if the bony removal has been extended to the low level of cavernous sinuses, so the surgeon can really peek in around their edges of the dura and remove tumor which is quite adherent to the medial wall of the cavernous sinuses. Here you can see diaphragmas sellae, maybe small amount of CSF weeping through the diaphragm. I will not allow the fear of small CSF leak to prevent me from aggressive tumor resection. And diaphragms sellae is manipulated, and the tumor along the falls of the diaphragm is removed aggressively. These are areas where the tumor is notoriously known for hiding, and more tumor along the tuberculum sellae. Inspecting the blind spots along the edges of the dura, making sure the tumor is adequately evacuated. You can see tumor can be hiding just underneath the edges of the dura within the operative blind spots of the surgeon. The diaphragm has to really nicely and freely hang down to confirm that the tumor has been aggressively removed. Here I mobilized the diaphragm using an angled suction device. You can see the usage of a very large angled ring curette. Again, the angle endoscope looking round over the medial wall of the cavernous sinus. Hemostasis should be very well secured, any residual tumor can provide a real risk of an anaplerotic event after surgery, and hematoma which will require emergent evacuation. Again, looking very well around the corners dorsum sellae making sure that the tumor is removed in a costeral fashion. Here is the left medial wall of carvenous sinus. The final product, large piece of fat was placed within the resection cavity. Again, buttressing the diaphragm not again indiscriminately filling the cavity, but placing it where the diaphragm is, so it can be buttressed very nicely to avoid postoperative CSF leak. Postoperative MRI evaluation revealed gross total resection of the tumor. Even though pre-operatively there was some evidence of cavernous sinus invasion you can see that the wall was relatively intact during the surgery, and across total resection of the tumor was possible, and this patient's vision significantly improved after surgery and his pituitary function tests remain intact. Thank you.

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